Queensland Health Reporting Concerns Portal

Non-Consumer Complaints Form

About you
First Name:
Last Name:
Gender:	Male Female
Date of Birth:	(dd/mm/yyyy)
Address:
Suburb:
State:
Post Code:
Phone:
Fax:
Email:	(required to send you a copy of your complaint)
Postal Address (if different to above)
Suburb:
State:
Post Code:
EEO Target Groups:
Women Aboriginal and Torres Strait Islander people People from a non-english speaking background People with a disability
Please let us know if you require any of the following assistance:
Hearing Impaired Visually Impaired Interpreter (specifiy language) Other (specify)
Please provide details of the event or issue you are lodging the complaint about
Date of event:
Indicate your status:
QH Employee Contrator Volunteer Member of the public
Facility Name:
Facility Location:
Details of the event: (Please provide as much detail as possible e.g. places, dates, times, names and titles)

What would you like to see happen as a result of raising these concerns?

Have you lodged your complaint with another organisation? (e.g. The Health Quality and Complaints Commission or other complaints organisation)
Yes No
If yes, please give details of any outcome to date: